Basic Information
Provider Information | |||||||||
NPI: | 1700975174 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAYES | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 190 | ||||||||
Address2: |   | ||||||||
City: | TOPPENISH | ||||||||
State: | WA | ||||||||
PostalCode: | 989480190 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098655898 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1175 MOUNT HOOD AVENUE | ||||||||
Address2: |   | ||||||||
City: | WOODBURN | ||||||||
State: | OR | ||||||||
PostalCode: | 97071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039822000 | ||||||||
FaxNumber: | 5039820660 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 12/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD26120 | OR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | M066528 | 01 |   | PACIFIC SOURCE | OTHER | 865416001 | 01 | OR | REGENCE | OTHER | 911019392 | 01 |   | COMMERCIAL | OTHER |